Hindawi Publishing Corporation Case Reports in Radiology Volume 2013, Article ID 479836, 4 pages http://dx.doi.org/10.1155/2013/479836 Case Report Bilateral Adrenal Hemorrhage in a Patient with Myelodysplastic Syndrome: Value of MRI in the Differential Diagnosis Lucia Manganaro, Najwa Al Ansari, Flavio Barchetti, Matteo Saldari, Claudia Vitturini, Marianna Glorioso, Valeria Buonocore, Giovanni Barchetti, and Francesca Maccioni Department of Radiological Sciences, Oncology and Pathology, University of Rome, Sapienza, Italy Correspondence should be addressed to Najwa Al Ansari; [email protected] Received 13 October 2013; Accepted 10 November 2013 Academic Editors: B. J. Barron and K. Hayakawa Copyright © 2013 Lucia Manganaro et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Bilateral adrenal hemorrhage is a rare potentially life-threatening event that occurs either in traumatic or nontraumatic conditions. The diagnosis is often complicated by its nonspecific presentation and its tendency to intervene in stressful critical illnesses. Due to many disorders in platelet function, hemorrhage is a major cause of morbidity and mortality in patients affected by myeloproliferative diseases. We report here the computed tomography and magnetic resonance imaging findings of a rare case of bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome, emphasizing the importance of MRI in the differential diagnosis. 1. Introduction blood pressure was 110/80 mmHg. Laboratory tests revealed a 3 platelet count of 82,000/mm , prolonged INR (International Acute bilateral adrenal hemorrhage is an extremely rare Normalized Ratio) and aPTT (activated partial thromboplas- disorder and it is difficult to diagnose because of its non- tin time), hyponatremia, hyperkalemia, and anemia, normal specific presentation [1]. This condition frequently occurs in serum electrolytes, lipase, and amylase levels. association with an extreme physical stress and may lead to A multislice computed tomography (MSCT) scan (Light- acute adrenal insufficiency or death if not promptly and prop- speed GE Medical Systems, Milwaukee, WI, USA) of the erly treated [2]. In adults, major causes of bilateral adrenal chest, abdomen, and pelvis was performed with administra- hemorrhage are the presence of meningococcemia or sepsis tion of 110 mL of intravenous contrast agent (Iomeron 350, from any organism [3], underlying adrenal tumors, burns, or Bracco, Milan, Italy) at a speed of 4.0 mL/s. The exam revealed hypotension related to hemorrhagic diathesis, especially the bilateral and symmetric enlargement of the adrenal glands one caused by uncontrolled anticoagulation [4]inpatients which were round and with hyperdense areas on precontrast treated with heparin, warfarin, or direct thrombin inhibitors. scans (each gland attenuation values were of 55 Hounsfield We report a rare case of acute bilateral adrenal hemorrhage Units on an average), consistent with recent bleeding. Mild in a patient affected by myelodysplastic syndrome. peripheral heterogeneous enhancement on the arterial phase, stranding of the periadrenal fat, and pleural effusion were also 2. Case Report detected, whereas there was no evidence of lymphadenopathy (Figure 1). The patient was treated with blood transfusions A 65-year-old man affected by myelodysplastic syndrome, and a prompt adrenal hormone replacement therapy, with but not already treated, was admitted to the emergency glucocorticoids combined with mineralocorticoids. room with suspected pancreatitis. He complained of dyspnea, After one week, an abdominal magnetic resonance imag- nausea, vomit, and acute epigastric pain with radiation to the ing (MRI) exam was performed to better evaluate the back.Therewasnohistoryoftraumaoranticoagulanttherapy adrenal glands (Avanto 1.5T, Siemens HealthCare, Erlangen, and he denied fever, hematuria, and urinary symptoms and Germany). Multiplanar (axial, coronal, and sagittal) T1- and 2 Case Reports in Radiology (a) (b) (c) (d) Figure 1: Axial non-contrast-enhanced CT image (a) shows bilateral adrenal enlargement (white arrows) with high attenuation values. Axial contrast-enhanced CT image (b) shows a bilateral homogeneously enhancing adrenal mass with solid appearance. Note the stranding of the periadrenal fat (black arrow) and the lack of regional lymphadenopathy. T2-weighted with and without fat saturation, T1-weighted common physical and laboratory findings are abdominal in-phase and out-of-phase spoiled gradient-recalled-echo pain, fever, hypotension, confusion, decreased hemoglobin (GRE), DWI, and ADC images were acquired. level (greater than 1.5 g/dL), and prolonged international MRI revealed bilaterally enlarged adrenal glands: the normalized ratio (greater than 1.4). Survival from bilateral diameter of the left adrenal gland was 65 mm and the diam- adrenal hemorrhage usually requires prompt adrenal hor- eter of the right adrenal gland was 40 mm. Heterogeneous mone replacement therapy, either with glucocorticoids alone hyperintensity, consistent with subacute hemorrhage, was or glucocorticoids combined with mineralocorticoids. detected on both T1- and T2-weighted images. The exam The pathophysiology of bilateral adrenal haemorrhage is also showed a subtle signal loss on T1-weighted in-phase stillunknown.However,someparticularanatomicfeaturesof GRE images compared to the T1-weighted GRE out-of-phase theglands,suchasaricharterialbloodsupplythatfeedsinto images and a mild heterogeneous peripheral enhancement a dense and delicate subcapsular capillary network through after contrast (MultiHance, Bracco Diagnostic, Milan, Italy) limited venules, predispose adrenal medulla to venous con- injection (Figure 2). Finally, on contrast-enhanced MR sub- gestion and thrombosis. Stress, increasing corticotrophin tracted images the hematomas appeared as areas of signal secretion, produces a dramatic rise in blood flow and the risk void, excluding the presence of a hemorrhagic neoplasm of hemorrhagic infarction [7]. (Figure 3). Although bilateral adrenal hemorrhage is classically asso- ciated with meningococcemia (Waterhouse-Friderichsen 3. Discussion Syndrome), it may occur in sepsis from any organism [8]. Traumatic events, burns, pregnancy, antiphospholipid The exact incidence of adrenal hemorrhage in the general syndrome, heparin-associated thrombocytopenia, throm- population is unknown, although some postmortem studies bophilic syndromes, anticoagulant therapy, and abdominal have found a prevalence of 0.14–1.1%. Many cases do not surgery are some of the other causes of adrenal bleeding [9– have specific signs of adrenal insufficiency, which usually 11]. occurs in patients with damage of more than 90% of the Hematomas can also arise in the setting of preex- adrenal cortex, and the diagnosis is incidentally made on isting adrenal neoplasms, such as pheochromocytoma, imaging performed for other reasons [5]. Unilateral adrenal myelolipoma, melanoma, neuroblastoma, adrenocortical car- hemorrhage can be usually managed conservatively, whereas cinoma, hepatocellular carcinoma, and lung cancer metas- bilateral presentation is often life-threatening and, due to its tases and should be suspected when CT or MR imaging shows no specific clinical symptoms, it can only be diagnosed at the a hemorrhagic adrenal mass of heterogeneous attenuation or time of surgery or at postmortem examination [6]. The most signal intensity that demonstrates enhancement [12–15]. Case Reports in Radiology 3 (a) (b) (c) (d) Figure 2: Bilateral enlarged adrenal glands with high signal intensity on axial T2- ((a), (b)) and T1-weighted (c) MRI images obtained before administration of gadolinium. Axial T1-weighted images (d) obtained after contrast injection reveal hyperintense masses with mild heterogeneous enhancement in hepatic arterial dominant phase. (a) (b) Figure 3: On axial contrast-enhanced subtracted MR images (a), (b) any signal from blood products is removed and the hematoma appears as a signal void (white arrows) because it does not contain enhancing elements, excluding the presence of a hemorrhagic neoplasm. Due to number and function platelet alterations, throm- hematomas from other adrenal pathologies, particularly neo- botic and hemorrhagic diathesis represents an event which plasms. In the first pattern the hemorrhage appears as a round may occur in myelodysplastic syndromes (MDS) [16]. or ovoid solid adrenal mass with an attenuation comparable Dayyani et al. have studied the most common disease-related to the soft tissue, as in our patient. With this CT findings, causes of death in patients with lower-risk myelodysplastic high density on precontrast scans and diminishing size or syndrome. Infection (38% of all deaths), transformation to resolution of the adrenal masses are usually diagnostic of AML (15%), and fatal hemorrhage (13%) constituted 96% hematomas, whereas the presence of a rim of enhancing does of all known causes of MDS-related deaths. Hemorrhage not permit distinguishing adrenal bleeding from neoplasm occurredinthecentralnervoussystemin26%,andgas- [18–20]. In addition to this, all types of adrenal hemorrhages trointestinal bleeding and pulmonary hemorrhage each was may liquefy, calcify, or become pseudocysts over time and responsible for 24% of bleeding-related deaths [17]. should be evaluated further in suspected cases. To our knowledge, CT and MRI